From the same case as the last, after taking Digitalis for 20 days. Pressure, 1 ozs.

Woman, æt. 62. Aorta good. Free regurgitation. Simulates high arterial pressure. Pressure, 1 oz.

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A typical 'splash' or 'water-hammer' pulse. Pressure, 2 ozs.

Aortic regurgitation under the influence of Digitalis. Violent systole.

MITRAL REGURGITATION.

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A boy, aged 10, with much dilatation and mitral regurgitation, showing the short, collapsing systole. Pressure, 1 oz.

EFFECT OF DIGITALIS.

The characteristic rapid, irregular, and failing heart of mitral regurgitation with dilatation. Pressure, 1 oz.

CHAPTER VI.

THE ALIMENTARY CANAL.

THIS gives a variety of indications, from the uncomfortable pharyngeal hawking of dyspepsia to the pruritus ani of seatworms or the worry of an external pile. The first act of importance is the modification of the act of swallowing, or dysphagia.

Dysphagia. This may be due to an abscess behind the pharynx, to oedema of the epiglottis, or enlarged cervical glands. It is more commonly associated with aneurysm of the great vessels of the root of the neck, and with stricture of the œsophagus; or it may be a foreign body impacted in the gullet. In stricture in a young woman it will probably be hysterical; in an elderly man it is usually cancerous, though it may be a fibrous stricture brought on by swallowing soaplees, for instance, or it may be neurosal. So far as is known to me, the characters of the act of swallowing in dysphagia have not been carefully studied. Usually there is only the capacity to get down small quantities at once in stricture or pressure. Some time ago, I was called far away to a case where there was dysphagia, with little else, only a patch of dulness at the back. Consequently, it became essential to study the act of swallowing carefully. A small quantity was certainly returned, while half a tumberful of fluid could be gulped down successfully. The opinion given was, that there was partial paralysis of the gullet (corresponding to the area of dulness at the back), and that it was not stricture

nor pressure; and the opinion was verified by the gradual disappearance of the dysphagia. Further observation of the act of swallowing would probably repay the trouble taken.

Vomiting. This is due, not only to the contraction of the stomach itself, but of the diaphragm and abdominal muscles. It is said, in one case at least, of poisoning by a corrosive acid, a large piece of the stomach was vomited before the patient died. Vomiting may be due to three causes. It may be primary in the stomach; reflex, as in renal calculus, or pregnancy; or it may be cerebral. At other times the vomited matter is fæcal, or urinous; or it may be a part of a general disturbance. It is common at the outset of fever, or in choleraic diarrhoea; this may be termed 'symptomatic vomiting.'

'Primary vomiting' may be due, either to matters taken into the stomach, or to ideas associated with them, or to some condition of the stomach itself. With babies it is quite common to see vomiting from too liberal a supply of food, the excess merely being rejected and the remainder retained. With some people all shell-fish produce vomiting without any apparent explanatory reason. In other cases, some special article of food, ordinarily well-borne by others, is always productive of sickness. Nauseating articles will lead to vomiting. So will 'nauseating' ideas. Rats are readily eaten when prepared as rabbits, and enjoyed, I am told; but the announcement of the real nature of the palatable viand swiftly produces free emesis.

Then, as to the condition of the stomach. Vomiting is common with all morbid conditions of it, as it procures physiological rest for the viscus. It may be set up by merely taking food into the stomach, as in gastric ulcer, and acute congestion from alcoholic indulgence. In the latter, there is 'morning vomiting' of frothy mucus and loathing of food (usually, too, a foul breath, a loaded tongue, and evidences of nervous unsteadiness-together with the un

truthfulness of the drunkard-are found with it). Gastric catarrh is not always alcoholic, and the food may be returned covered with mucous slime. Here time must have elapsed for the mucous covering to be formed. Immediate vomiting is due, either to gastric ulcer, or congestion of the stomach, or some toxic irritant. In the latter case it is suddenly developed, and may readily pass away. In ulcer the opposite is the case, as it is a chronic affection. When the stomach is at rest and alkaline, then the ulcer does not make itself felt. But let food be taken, and then the gastric movements begin dragging on the base of the ulcer, and the acid gastric juice is poured out; and betwixt the two acute pain is produced. Vomiting by placing the stomach at rest, in both ways, anatomically and physiologically, at once gives relief. Consequently, it has a high diagnostic value, this sudden ease after vomiting is set up. In cancer of the stomach the pain is not so strictly related to the taking of food, nor so pronouncedly relieved by vomiting.

The matter vomited is often instructive. When it consists of focal matter it tells of intus-susception above the ilio-cœcal valve, or of a perforating ulcer between the stomach and the transverse colon. There is 'stercoraceous vomiting here. In some chronic renal conditions the vomited matter is distinctly urinous in odour; this is 'uræmic' vomiting. Sometimes bile is mixed with the vomit; it may be due to liver disorder, but bile is often thrown up when the act of vomiting is severe or prolonged. Blood is not uncommon, especially in yellow fever. The 'Black' vomit is a symptom of the worst prognostic omen. 'Coffeeground' vomit may be due to a congestive outpouring, or to a minute hæmorrhage. Blood of high colour tells of an ulcer eroding a blood-vessel, or acute congestion. It may be a form of vicarious menstruation. Indeed, in females, it is well to see whether the hematemesis be rhythmic, coming on at intervals, corresponding to the catamenial